GOVERNMENT OF BRUNEI DARUSSALAM SCHOLARSHIP

FOR FOREIGN STUDENTS TENABLE IN

BRUNEI DARUSSALAM

ACADEMIC SESSION 2021/2022

APPLICATION FORM

CODE PROGRAMME NAME INSTITUTION

UBD
Bachelor of Shariah √ UNISSA
FIRST CHOICE S002
(Fiqh & Ushul) UTB
PB
UBD
√ UNISSA
SECOND CHOICE U004 Bachelor of Usuluddin UTB
PB

INSTRUCTIONS TO APPLICANTS

1. Each applicant must complete this form by typing; handwriting in this case is not
allowed.

2. The following documents MUST be submitted along with this form:

i. Recent passport size photographs.
ii. Certified true copies of academic qualifications and other supporting documents (i.e.
certificates, testimonials, transcripts).
iii. Certified English translations of supporting documents must be submitted for
documents that are not in English.
iv. Applicant’s Statement of Purpose (Item 6).
v. Certified true copies of Birth Certificate and Passport.
vi. Security Vetting from country of origin/residence.

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1. PERSONAL AND CONTACT DETAILS (Please use BLOCK Letters)

Name (Please underline surname):

MUHAMMAD REVANZA

Passport No:C6929502 Citizenship:INDONESIA

Date of Birth ( dd/mm/yyyy ):19/01/2000 Country of Birth:INDONESIA

Religion:ISLAM Ethnicity:MALAY / MINANG

Marital Status: SINGLE Gender: MALE

Postal Address: KORONG PADANG SAGO RANDAH NAGARI KOTO DALAM SELATAN
KECAMATAN PADANG SAGO KABUPATEN PADANG PARIAMAN,WES SUMATRA 25522

Telephone No.:+62 - 857- 8296 - 9020 Fax No.: -

(country code) (area code) (tel no.) (country code) (area code) (tel no.)

Mobile No.: +62 - 821 – 1451- 3401

(country code) (area code) (tel no.)

E-mail address (if any): [email protected]

(Candidates are strongly advised to provide either an email address or fax number to facilitate
correspondence)

Name of Parent/ Guardian/ Next of Kin*: DASRIANTO

Relationship: FATHER

Occupation / Designation: TRADERS

Address: KORONG PADANG SAGO RANDAH NAGARI KOTO DALAM SELATAN KECAMATAN
PADANG SAGO KABUPATEN PADANG PARIAMAN 25522

Contact Number/ Email Address: 081365704342

*delete as appropriate

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2. EDUCATION EXPERIENCE (Details of schools attended and academic qualifications)

A. Please state all schools attended from the age of 15

Name of School/ Institution From To Qualifications Obtained
Pesantren Al-Munawwaroh 2015 2017 Graduate of theTsanawiyah
Madrasa
Pesantren Modern Ummul Quro Al- 2017 2019 HIGH SCHOOL DEGREE
Islami

B. General Certificate of Education (Ordinary Level or Equivalent)

(Please state subjects that you have passed only)
Year Subjects Grade Medium Examination Body
2017 Al-Quran-Hadith Exellent INDONESIAN/ Ministry of Religion
ARABIC Indonesia

2017 FIQH Exellent INDONESIAN/ Ministry of Religion

ARABIC Indonesia

2017 History of Islam Exellent INDONESIAN/ Ministry of Religion

ENGLISH Indonesia
2017 Arabic Language Exellent INDONESIAN/ Ministry of Religion
ARABIC Indonesia

2017 English Language Very English Ministry of Religion

Good Indonesia
2017 Mathematics Very Indonesian Ministry of Religion
Good Indonesia
2017 Ushul Fiqh Exellent Arabic Ministry of Religion
Indonesia
2017 Social Science Exellent Indonesian Ministry of Religion
Indonesia

2017 Nahwu & Shorof Exellent Arabic Ministry of Religion

Indonesia
2017 INFORMATION AND Exellent Indonesian Ministry of Religion
COMMUNICATION Indonesia
TECHNOLOGY

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C. General Certificate of Education (Advanced Level or Equivalent)
(Please state subjects that you have passed only)
Year Subjects Grade Medium Examination Body
2019 Tafsir Al-Qur’an Exellent Arabic Ministry of Religion
Indonesia

2019 Nahwu & Shorof Exellent Arabic Ministry of Religion

Indonesia

2019 The History of Islamic Exellent Indonesia/ Ministry of Religion

Culture English Indonesia

2019 Arabic language Exellent Arabic Ministry of Religion

Indonesia

2019 Ushul Fiqh Exellent Arabic Ministry of Religion

Indonesia
2019 Masail Diniyah Exellent Arabic Ministry of Religion
Indonesia
2019 Sociology Very Indonesia Ministry of Religion
Good Indonesia
2019 English Language Very English Ministry of Religion
Good Indonesia
2019 Mathematics Very Indonesian Ministry of Religion
Good Indonesia
2019 Economy Very Indonesian Ministry of Religion
Good Indonesia
2019 Geography Very Indonesian Ministry of Religion
Good Indonesia

D. Other Qualifications (Certificate/ National Certificate/ National Diploma/ Higher National

Diploma/ First Degree)
Qualifications Name of Institute & Duration Date Classification/ Medium of
Country Passed Grade Instruction
MTS AL- 3 2017 EXCELLENT INDONESI
MUNAWWAROH Years A
MA UMMUL QURO AL- 3 2019 EXCELLENT INDONESI
ISLAMI YEARS A
PROGRAM DAARUL KHULUUD 1 2020 EXCELLENT INDONESI
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 FOR YEAR A
MEMORING
THE QURAN

E. Intended Qualification
Name of Programme/ Course Subjects Date of Results Expected
Bachelor of Shariah BACHELOR 2021
(Fiqh & Ushul)
Bachelor of usuluddin BACHELOR 2021

3. LANGUAGE PROFICIENCY
Language Written Reading Spoken
English
X X X
1 2 3 1 2 3 1 2 3
Others, Please State:
X X X
i. Indonesia 1 2 3 1 2 3 1 2 3

ii. Arabic X X X
1 2 3 1 2 3 1 2 3
1: Good 2: Average 3: Poor

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4. ACADEMIC DISTINCTIONS OR PRIZES RECEIVED

Has completed memorizing the Qur'an 30 Juz

5. PROPOSED FUTURE CAREER

I have aspired to build a religious madrasa / pesantren to the university level where

students memorize the al-qur'an and can understand sharia, namely the books of salaf

scholars by understanding tools such as nahwu and sorof

my goal is only to be useful for others in terms of goodness, and therefore I studied

religion well first and was good in the field of education

so that I can practice the knowledge that I have obtained from the community, God

willing.

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6. APPLICANT’S STATEMENT OF PURPOSE

In an essay of up to 200 words, describe your plan of study and/ or research you propose to
pursue and relate this to your future career plan.
(You may include additional relevant material if there is insufficient space on this form).

From a young age I wanted to study religion and I aspired to become a scholar who could
be useful for many people because my teacher once said that the good people are the
ones that benefit other human beings, and I want to take this scholarship because I want
to increase my insightful experience,and my religious knowledge and also most
importantly I want to ease the burden on my parents so that the costs can be for my
younger siblings,and insha allah my target is after I get a scholarship in Brunei
Darussalam later I want to continue my studies, God willing, to a higher level,I want to
establish a religious madrasa/Islamic boarding school that teaches the Koran and Islamic
sharia because what I have seen is rarely religious education that can focus on those 2
fields and I aspire to make it happen after I finish,so I take the major in religion to further
explore.Many of my family hopes that I can study there because God willing, it will be an
example and motivation for other parents so that their children can also study religion
and more and more young people who will be educated and understand religion.

Please tick if additional materials are enclosed

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7. WORK EXPERIENCE (Please attach additional information if required)
Part-Time/ Dates
Employer’s Name and Address Position Held
Full-Time From To
Mosque Administrator Administrator Full Time 2019 2020
Al-Quran Teacher Teacher Part-Time 2020 2021

8. EXTRA CURRICULAR ACTIVITIES

(Please attach additional information if required)
Year Types of Activities (Sports, Cultural, Level of Participation (e.g. Club, District,
Community Services etc.) National, Regional, International etc.)
2015 Language Improvement Center Club
2016 Scout Club
2017 Language Centre Club
2017 Silat Kumango Club

9. MEMBERSHIP IN ASSOCIATIONS/ PROFESSIONAL BODIES

(Please attach additional information if required)
Year Associations/ Professional Bodies Position Held
2015 Ispa Ta'lim Section Chairman Section
2016 ISPA Rayon Parts Chief Of Dormitory
2017 Student Council Administrator Security Section
2018 Member Show of The Dreamer Consumption Section

10. ACADEMIC AWARDS/ SCHOLARSHIP ACHIEVED, IF ANY

Academic Awards/ Scholarship Institution Name Date Awarded

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 C1
GOVERNMENT OF BRUNEI DARUSSALAM SCHOLARSHIP FOR FOREIGN STUDENTS
‘REFERENCE LETTER’

Assessment on the applicant’s academic ability.

1. Applicant’s Name:MUHAMMAD REVANZA

Country:INDONESIA

Courses Applied:Bachelor of Shariah (Fiqh&Ushul)/ Bachelor of Ushuluddin

2. In what capacity do you know the applicant? (e.g. teacher, supervisor, Principal etc.)
Chairman of Baldatun Thoyyibah Foundation

3. How long have you known the applicant? 2 Years

4. Please evaluate the applicant’s performance by putting an X in the appropriate spaces

below. Extra boxes are available if you wish to add up to three other qualities which you may
find relevant to the assessment of the candidate (E.g. All-round ability, ingenuity,
accountability, manual dexterity etc.)
Assessment on: Excellent Very Good Good Average Below Average
Academic Record X
English Proficiency X
Creative Thinking X
Research Ability X
Industry/ Application X
Judgement X
Independent X
Honesty X
Motivation X
Self Discipline X

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GOVERNMENT OF BRUNEI DARUSSALAM SCHOLARSHIP FOR FOREIGN STUDENTS
‘REFERENCE LETTER’

Assessment on the applicant’s academic ability.

1. Applicant’s Name: Muhammad Revanza

Country: INDONESIA

Courses Applied: Bachelor of Shariah (Fiqh&Ushul)/ Bachelor of Ushuluddin

2. In what capacity do you know the applicant? (e.g. teacher, supervisor, Principal etc.)
Teacher

3. How long have you known the applicant? One Year

4. Please evaluate the applicant’s performance by putting an X in the appropriate spaces

below. Extra boxes are available if you wish to add up to three other qualities which you may
find relevant to the assessment of the candidate (E.g. All-round ability, ingenuity,
accountability, manual dexterity etc.)

Assessment on: Excellent Very Good Good Average Below Average

Academic Record X
English Proficiency X
Creative Thinking X
Research Ability X
Industry/ Application X
Judgement X
Independent X
Honesty X
Motivation X
Self Discipline X

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